Archive for the ‘parentlng’ Category

I have written before in this space about special needs children, including children with autism. This week I want to turn my attention to one aspect of autism – wandering – and some of the ways parents and schools are trying to keep kids safe. Wandering is something I really had not heard of before, but I’ve since learned that it is a serious danger to children with autism or other cognitive deficits. It is also a major source of stress to parents who are constantly worried about their child wandering off.

All children have a tendency to wander away from their parents at times. When my daughter was two, I lost her at Sports Authority. I thought she was standing right next to me while I was looking at something, then I looked down and she was gone. After a few frantic minutes – and with the quick help of the store employees – we found her all the way on the opposite side of the store looking at balls. She was perfectly fine, but it was terrifying for me.

According to the responses from more than 800 parents, roughly 50 percent of children between the ages of 4 and 10 with an ASD wander at some point, four times more than their unaffected siblings. The behavior peaks at 4, almost four times higher than their unaffected siblings, but almost 30 percent of kids with an ASD between the ages of 7 and 10 are still eloping, eight times more than their unaffected brothers and sisters.

Autistic children seem to wander for two basic reasons. One is to find something they like, such as their favorite pond or playground; and one is to get away from something they don’t like such as a stressful school environment. It’s not really running away, at least as that term is usually used to describe a child who decides to leave home because of some real or perceived injustice at home. A majority of parents in the study described their child as happy and focused when they wandered off. It is usually a matter of the child being drawn to something that he or she likes. One child referenced in the Child Mind story had a fascination with exit signs. One day at school, the boy wandered off through the woods toward the highway to find his favorite exit sign. Thankfully, a good Samaritan picked-up the boy and returned him to where he belonged.

The danger for children is very real. While concrete statistics are difficult to come by, drowning seems to be the biggest danger (there are some who believe that autistic children are drawn to water). Children can also wander into traffic. Of course, when any small child wanders alone there is the risk of getting lost or being abducted. To further complicate matters, thirty-five percent of families in the study reported that their child is never or rarely able to communicate basic identifying information such as name, address and phone number. This obviously makes it harder for a wandering child to get back home. Even older or more high-functioning children may – due to their social anxiety – be reluctant to seek out help or cooperate with someone who is trying to intervene.

Wandering represents a challenge to schools because it can be very difficult to monitor a child all day long, especially during class changes and recess. The problem, however, also occurs at home. Wandering occurs not just during the day; night-time wandering is an especially big fear for parents of autistic children. Some children have been known to get up in the middle of the night, undo the deadbolt on the front door, and walk-off into the night. The terror of finding your child gone in the middle of the night is unimaginable. Some parents have installed deadbolts higher up on the doors, some have installed alarms that go off if the door is opened. Some parents have gone so far as to have their children wear tracking devices that send out a signal that can be pin-pointed. While all of these techniques can help, there are no sure-fire methods of preventing wandering. It is a constant worry for parents.

The autism community has taken action by getting the Center for Disease Control’s safety subcommittee to assign a specific medical code for wandering, which will be in conjunction with the diagnosis of ASD. By doing this, it is hoped that doctors will more readily recognize wandering as a legitimate diagnosis that they can address with the parents or other caregivers (the new code applies to adults with ASD as well). The American Academy of Pediatrics is also preparing a fact sheet to educate doctors on the topic so that they can better work with parents to try to reduce the incidence of wandering. The new code may also make it easier for parents to seek reimbursement from their insurance companies for alarms and tracking devices, and it may make it easier for parents to argue to their schools that a one-on-one monitor is needed as part of the child’s Individualized Education Plan (IEP). The new code takes effect in October 2011.

The best overall strategy is a multi-tiered approach, which includes educating the child about safety and dangers using whatever means of communication works, including social stories, language and/or visual prompts. It’s also important that caregivers—and schools—work to understand what is causing, or contributing to, the wandering or bolting behaviors so that any triggers may be addressed or eliminated.

Have any of our readers had any experience with wandering? I’d like to hear your stories as to how you deal with it and how it affects your life.

A while back I wrote a piece on the topic of service dogs for kids and mentioned the use of service dogs in schools. A regular reader of our blog then wrote in with a number of comments and questions about the propriety of dogs in schools. To help answer her questions, I recently spoke with Nancy Fierer, who is the Director at Susquehanna Service Dogs in Harrisburg, Pennsylvania, which is an organization that trains and places service dogs. Susquehanna is the organization that placed two of the dogs mentioned in this NPR story.

The ADA and dogs in school

I also did a little more research on the Americans with Disabilities Act (“ADA”) and its impact on the issue. The ADA requires that all public facilities allow a disabled person and his or her service dog (not pets) to enter the premises just the same as a non-disabled person. So is a school considered a public facility? It’s an interesting question. On the one hand it is accessible to the public in the sense that parents and students can freely enter a school. However, if you’re not the parent of a child at the school, can you just walk into a school and roam the halls like you might roam around a mall? I think if you tried that, you would get stopped pretty quickly and asked to leave if you had no valid business there. However, the law appears to be settled that schools are considered public facilities at least for those areas that are open to the public such as administrative offices, gymnasiums during sporting events, and auditoriums during public events. Therefore, schools must be accessible to service dogs in these public areas. For class rooms, however, it’s not so clear. While the law appears to favor allowing service dogs in class rooms, it is being decided on a case-by-case basis because there are other considerations as well – the age of the child, the disability at issue, the ability to control the dog, etc.

How much school assistance is necessary?

I have to admit that when I first wrote on this topic, I had envisioned that the dog and child were a self-contained unit that required little in the way of adult assistance. Ms. Fierer indicated that that is usually not the case. Depending on the age of the child and the level of disability, the child may be able to care for the dog independently. However, in most instances an adult (teacher’s aide or nurse perhaps) is required to pitch in with help giving the dog water and taking it out for bathroom breaks. Ms. Fierer indicated that the dog does need water breaks during the day (feeding can be done at home before and after school). This is usually accomplished by keeping a water bowl in a nearby room – perhaps a nurse’s office or a counselor’s office. Several times a day, either the child (if he/she is old enough) or an adult can take the dog for a drink. The same is true for bathroom breaks (pee only; No. 2 is usually taken care of at home). Again, service dogs do require assistance from the school but from what Ms. Fierer told me, the disruption is fairly minimal and can be worked out with proper planning.

Controlling a service dog

A larger issue is the child’s ability to control the dog. Even though service dogs are highly trained, the owner (in this case a child) must still be able to control the dog before being permitted to take a dog into school. These include such basic commands as making the dog sit, stay, come, leave it, and walk on loose leash. These are some of the common commands that all service dogs must know. In addition, a service dog also receives additional training in a particular disability and learns specific commands unique to that disability, e.g., retrieving specific items, pulling a wheelchair, responding to seizures, search and rescue. These commands must be mastered as well. For example, if an autistic child is in need of the dog to put its head in the child’s lap to help calm him/her down, the child (or a trained adult) has to be able to give the dog that command. If the child cannot give that command to the dog, then it undermines the usefulness of the dog in school.

Because of the demands that service dogs place on the child, very young children usually do not take dogs to school unescorted. Ms. Fierer said she would be surprised to see a six-year-old, for example, taking a dog to school alone. Older children can, with proper training, be permitted to take a dog to school alone. To ensure that the child is capable of caring for the dog, Susquehanna utilizes the Assistance Dogs International Public Access Test. This test requires the owner and the dog to perform multiple tests in a variety of settings to ensure that the dog is well-trained and that the owner can properly control the dog. For children, Ms. Fierer indicated that the testing is usually administered with the parent and child because she uses the team approach – the parent, child and dog are a team. For a child taking the dog to school, however, the parent is usually not there so the child must be able to control the dog independently. Only when a child is adept at controlling the dog should the child be permitted to take the dog to school. Even then, parents have to work closely with the child’s teacher and other school staff to coordinate the details of how the dog will be cared for.

Other concerns

Our reader also asked questions about whether service dogs are a distraction in school and whether they can pose a danger to other children. After talking to Ms. Fierer, it’s my opinion that these are not major concerns. As for being a distraction, Ms. Fierer said that is usually not the case. Service dogs are generally introduced into the school gradually, starting with maybe a half-hour per day and building from there. The children get accustomed to the dog and the novelty soon wears off. Also, the other children need to be educated that this is a service dog and not a pet to be played with. Children can easily learn this lesson. As for being a danger to other children, Ms. Fierer said she has never heard of a dangerous incident happening at school such as a dog biting a child. These dogs are amazingly well-trained and the trainers allow zero tolerance for aggressive behavior. If a dog shows any aggression, that dog does not make the cut for being a service dog. Therefore, I don’t believe this concern is a valid reason for denying a child a service dog.

Training a service dog

In terms of the actual training given to the dogs, Ms. Fierer said that when a puppy is eight weeks old, it starts living with a dedicated puppy handler who is responsible for teaching the dog basic manners. This time includes classes at Susquehanna twice per month. This arrangement goes on till the dog is 18 months old, at which time the dog receives about six months of intense training. About 50-60 percent of training is the same for all service dogs. The rest is devoted to the unique needs of each disability. Before a dog is placed, Susquehanna spends about 2 and ½ weeks training the family that is receiving the dog. Even after placement, Susquehanna continues to do follow-up training – at first on a weekly basis and then gradually declining over the next six months. It even does annual re-testing.

I hope this follow-up addresses our readers’ concerns. Ms. Fierer emphasized that service dogs are not the solution for every child. Susquehanna actually does therapy sessions with families before even agreeing to place a dog to ensure that the dog and the family are a good fit. She indicated that it is a big responsibility to own a service dog and it is not a decision that is made lightly by the dog trainers. However, for the right child and the right family, a service dog can be an amazing asset.

Eye Opener’s Week in Review

From the guest editor: Good morning! I was hoping that you would take a break from making your “to do” list to stop by and check in with us. As usual, we have been busy blogging. And practicing law. And getting ready for trial. And in trial! Needless to say, we have been pushing it to the limits. In truth, we wouldn’t have it any other way. Before we get back to trial preparation, lets take a step back and look at the past week.

What do you do when your opposing counsel forgets that the practice of law is a profession and not a blood sport? What do you do when the phase “zealous representation” gets confused with “obnoxious obstructionist behavior?” When faced with similar frustrations, Jon Stefanuca broke out his keyboard and explained what we litigators deal with on a day to day basis. Being a lawyer is a very rewarding profession, but like any other, it has its share of frustrations. Don’t take my word for it, read more…

Germs are in your kitchen. They are in your bathroom and your bedroom. They are on your fingertips and even on your tongue. And everyone knows that there are going to be germs in hospitals. Even the best hospitals have to work to keep the patients, rooms and visitors clean and safe. Sara Keogh reported on news that may make keeping hospitals and other health care environments less germy in the future. Two simple solutions, copper and duct tape, might have a major impact on infection control. Read more…

SneakPeakof the Week Ahead:

The Eye Opener and its writers are excited about the week ahead too! Here’s a sneak peakof what’s in store for you:

Service dogs for children: more than just a pet

Legal Boot Camp is back in session and Part IV of our Cerebral Palsy tutorial.

Eye Opener’s Week in Review

From the (guest) editor: Good morning! With the morning workout complete, I thought now would be a good time to take a look back. We had a sneaking suspicion that with the excellent weather forecast you might spend some time outdoors. Before you do, make sure you read our Summer Series. This week we gave you what you need to know before you (and your little ones) head to that family BBQ. Enjoy your Independence Day, drink a tall glass of fresh squeezed lemonade and enjoy!

As if life with HIV/AIDS is not difficult enough, researchers have also found that HIV/AIDS patients are also more prone to developing various malignancies when compared with the non-infected population. In fact, cancer is one of the leading causes ofmortality in the HIV/AIDS population. It is estimated that 30%-40% of HIV patients will develop some type of cancer during their life time. Read more…

We can all agree that “skin cancer” is bad. When we refer to skin cancer, what do we mean? Most often we are referring to squamous cell, basilar cell or malignant melanoma. On Tuesday, Sara described the different types of skin cancer and the associated rates and survival statistics. Read more…

So Sara’s piece on Tuesday convinced you that sunscreen is necessary? But how do you pick one? Last week, the FDA announced new regulations of sunscreen. If sunscreens meet the new legal standards, they can use certain marketing phrases so that consumers know what level of protection will be provided by the product. Read more…

Summer is heating up, and there are lots of outdoor activities in which to participate. Along with the thermostat, however, there is also a rise in the deer tick population! This equates to an increase in Lyme disease, the most commonly reported vector-borne illness in America! Maryland, Virginia, Pennsylvania, Delaware and New Jersey all all“hotbeds” for this disease, comprising 5 of the top 12 states comprising 95% of all Lyme disease cases nationwide. Before you leave for the family picnic, you should read more…

It is popular to “pre-bake” before hitting the beach. A tanning bed is often the The use of tanning beds or “indoor tanning” greatly increases a person’s risk of developing skin cancer. It is a completely voluntary exposure to UV radiation, and yet many people choose to expose themselves despite all of the risks. Before you opt to “fake and bake,” you should read more…

SneakPeakof the Week Ahead:

The Eye Opener and its writers are excited about the week ahead too! Here’s a sneak peakof what’s in store for you:

Service dogs for children: more than just a pet

Legal Boot Camp is back in session and Part IV of our Cerebral Palsy tutorial.

Eye Opener’s Week in Review

Jason Penn

From the Editor: Today marks the end of week two as “guest” editor for the Eye Opener. I can tell you that the title “editor” is a misnomer. When it comes to the Eye Opener and its panel of bloggers, very little (if any) editing takes place. Consistently, our blawgers provide you with timely and topical posts. This week was no different. Let’s take a retrospective look at what the “Eye Opener” offered this week (and, of course, a sneak peek at the week ahead.)

– Jason Penn, Guest Editor

(Many thanks to Jason and all those back at the firm, who helped get the word out on some great topics this past week while I’ve been wrapping-up week #2 of the trial from hell…….Brian Nash)

While the loss of sleep is rarely a topic on Gray’s Anatomy (or any made-for-television medical drama), it is a genuine quandary for non-actor, medical residents. This past Monday, Theresa Neumann explored the ACGME’s limitations on the hours worked by medical residents in the United States. As Theresa explained, the overall maximum hours per week will not change; it remains at 80 hours. One big change is the limit on the maximum continuous duty period for first year residents; this will be decreased from 24 to 16 hours. It will remain 24 hours for residents after their first year, but recommendations include “strategic napping.” Curious about the other changes? Read more…

Sleep isn’t only important for medical residents; it is also important for the smallest members of our families. As Sara Keogh explained on Tuesday, Maryland is considering regulations to ban the sale of crib bumpers. For many years, more and more emphasis has been placed on infants sleeping in safe cribs without any additional “stuff” in them. This has included the elimination of lots of former nursery staples. Baby blankets, stuffed animals, pillows and other loose items have been banned from the crib by safety experts for years. As requirements for cribs have required slats that are closer together, the utility of using a bumper to help a child from getting stuck between crib slats has been eliminated. More recently, the Consumer Product Safety Commission has developed even newer crib safety standards, including eliminating the use of drop-sides, and warned against the use of sleep positioners. Yet, despite the advice to put babies to sleep only on their backs in cribs empty of everything except a well fitting mattress and fitted sheet, many parents and caregivers persist in using other items in cribs. Now, with an increasing number of deaths associated with crib bumpers, Maryland is considering a stronger stance. Read more…

By: John Stefanuca

On Wednesday blogger Jon Stefanuca broke out his calculator: bootcamp style. In the state of Maryland, there is a cap on the damages that can be awarded. But what happens when a jury returns a verdict in excess of the statutory amount? Mathematics and law intersect.

To see the results, and a detailed explanation of how it all works, you can read more ….

With the death of the always controversial Jack Kevorkian, we revisited a post by Theresa Neumann. Breathing a little life into the post (pun intended), Theresa provides an excellent primer for readers that are facing end of life situations. The differences are nuanced and can be difficult to understand at a most difficult time. Are you sure you know the difference between palliative, end-of-life and hospice care? Read more…

When Humpty Dumpty fell, they were able to put him back together again. Because our lives are nothing like a children’s nursery rhyme, when we fall, we get hurt. A head injury is particularly serious. Have you ever bumped your head and developed a “goose-egg?” It’s truly amazing how fast that big bruise under the skin grows. That bruise, or hematoma, is from a broken blood vessel, usually a vein. The pressure from the swelling helps with clotting, along with the blood’s own clotting factors. This types of hematoma typically takes a week or more to go away. If it’s on the forehead, it’s often followed by one or two “black eyes.” That’s because the blood tends to spread along tissue planes, and gravity notoriously pulls everything downward causing it to pool in the eye sockets, where the blood cells degrade and their components are reabsorbed by the body. Unlike a fairy tale, however, this goose-egg can be serious. Read more…

Sneak Peak of the Week Ahead:

As I told you at the beginning, the Eye Opener’s writers continue in their efforts to provide you with timely and topical blogs for your reading pleasure. As evidenced by the above, this past week was no exception. The Eye Opener and its writers are excited about the week ahead too! Here’s a sneak peak of what’s in store for you:

Service dogs for children: more than just a pet

Changes in Sunscreen: will regulation prevent cancer?

HIV Patients: Increased risk for developing cancer

Legal Boot Camp is back in session and Part III of our Cerebral Palsy tutorial.

In the newest topic regarding crib safety, Maryland is considering regulations to ban the sale of crib bumpers. For many years, more and more emphasis has been placed on infants sleeping in safe cribs without any additional “stuff” in them. This has included the elimination of lots of former nursery staples. Baby blankets, stuffed animals, pillows and other loose items have been banned from the crib by safety experts for years. As requirements for cribs have required slats that are closer together, the utility of using a bumper to help a child from getting stuck between crib slats has been eliminated. More recently, the Consumer Product Safety Commission has developed even newer crib safety standards, including eliminating the use of drop-sides, and warned against the use of sleep positioners. Yet, despite the advice to put babies to sleep only on their backs in cribs empty of everything except a well fitting mattress and fitted sheet, many parents and caregivers persist in using other items in cribs. Now, with an increasing number of deaths associated with crib bumpers, Maryland is considering a stronger stance.

Danger of Crib Bumpers

The concern about crib bumpers is that there have been infant deaths associated with suffocation or strangulation and the use of crib bumpers. Some of the deaths are directly attributable to the bumpers (for instance a child found with their head wrapped in the ties of the bumper or their face pressed into the side of the bumper), while others are only potentially related to the bumper use but not definitively so (for instance, children whose death are classified as SIDS, but where bumpers were in use in the crib at the time of death and may have been a contributing factor in the death). This makes the discussion of the dangers muddy – with manufacturers claiming that bumpers are safe and advocates warning against their use to protect against suffocation.

Potential Ban on Sale of Bumpers

When the Baltimore Sun reported on the potential regulations, they mentioned something that gave me pause. They explained that if Dr. Sharfstein, secretary of the state Department of Health and Mental Hygiene, does decide to regulate this issue, the regulations will impact only the sale, not the use of the bumpers. While this makes sense from a policy perspective, the goal is not to punish parents who may not be aware of the safety risks, and from a enforceability perspective, the state cannot possibly enforce a regulation that requires knowledge of whether bumpers are being used in individual homes, the regulation of the sale of the item is going to have some drawbacks.

Will a State Ban Save Lives?

So here are my questions. Will regulations against the sale of these bumpers in Maryland make any difference in saving lives? In this day of internet shopping and wide availability of items through catalogues and easy interstate travel, are Maryland families going to forgo the crib bumper because they cannot be purchased in the local baby store, or are they still going to be buying the bumper with a set of nursery items on Amazon or through a national baby store? Will Internet or national companies without a store presence in Maryland be punished for selling a bumper to a person with a Maryland address? If so, then perhaps the word will get out that these items are dangerous and should not be used. If not, will parents even realize that the goal of the regulation is actually to curb the use of the bumpers. Either way, I guess that by decreasing the number of bumpers in Maryland homes, safety will be increased and perhaps over time, awareness will be increased and other states may follow suit.

Getting the Word Out

My other concern is that if there are parents who are still using bumpers, blankets or other items in their babies’ cribs, is the issue one of parent education? Perhaps the real emphasis needs to be on wider parental awareness of the safety issue. There are lots of great resources available to learn how to put infants to sleep safely:

Since the early 1990s, the emphasis has been on having infants sleep on their backs. This has lead to a dramatic decrease in SIDS deaths since that time. The “Back to Sleep” campaign began in 1994 and continues to this day. However, when reading a 2005 paper from the AAP, I was surprised to read that SIDS deaths are more likely to occur when a baby who is used to sleeping on their back is placed to sleep on their stomach. This suggests that education needs to be of all potential caregivers since an occasional babysitter, grandparent or child care provider who is unfamiliar with the recommendations and the child’s normal sleep position may place the child to sleep on their stomach and cause real risk.

AAP has made many recommendations since 2005 including that children sleep in cribs with only a fitted sheet and without any additional soft bedding. These recommendations have varied somewhat over time on the use of bumpers and sleep positioners. However, the overall advice seems to remain the same – eliminate all soft bedding items. Despite these recommendations, there are still images in popular media of nurseries complete with cribs with soft bedding.

What changes are still needed?

What changes are needed to get the word out? Do you think that there needs to be a stronger effort to change the marketing images for infant products? Do you think that a ban on the sale of bumpers will have a significant impact on child safety? What about an education campaign focusing on caregivers, grandparents and day care providers?

We all know that a little over-the-counter (OTC) pain medication can be just what the doctor ordered for minor aches, pains or to help combat the symptoms of a nasty flu. Most adults, however, also realize that medications can be dangerous. No, I am not talking about the blast from the past news stories about medications that have been tampered with (…though it is weird that the Unabomber, Ted Kaczynski, is back in the news as one possible suspect in the Tylenol poisonings that killed people in the Chicago area in 1982). My focus today is on the danger involved with overdoses of commonly used pain medication. In particular, the risk of accidentally overdosing children on OTC pain relievers such as Tylenol.

Image from www.tylenol.com

There has been quite a bit of focus recently on the possible changes to Tylenol and other acetaminophen containing drugs for children. These are not formula changes and they have nothing to do with the myriad of Tylenol recalls over the past couple of years. Currently, the basic concern is that overdoses of this common medication accounts for a fairly sizeable number of poisoning cases, which can be very serious since overdose can cause liver damage to children. An AP article reports that:

Dosing errors with children’s acetaminophen products accounted for 2.8 percent, or 7,500, of the 270,165 emergencies reported to poison centers last year, according to the American Association of Poison Control Centers.

Overdoses can be caused by parents not reading the label, misinterpreting the dosing instructions or using a spoon or other container instead of the cup included with the product.

These overdose situations most often occur in children under 2 years old.

Chart provided on www.tylenol.com

When I read this, I was not surprised. Currently acetaminophen for children, Tylenol and other brands, come in two different concentrations. Most commonly one is labeled “Children’s” and the other “Infant’s.” Each of these medications include on the outside packaging a confusing little matrix that details the correct dosage for a child of a particular age or weight range. The correct dosing for your child’s age and weight may not be the same if you have a child that is particularly large or small for their age. Additionally, if you have both children’s and infant’s acetaminophen products in your home, you must be careful to provide the correct dosing for the correct concentration. This does not even get into the differences in dosing between the liquid medicine and the tablets. Finally, the box does not provide dosing information for children less than two years of age. The dosing instruction for children under 24 months is “ask your doctor.” So, how many of you are going to make that phone call?

The harsh realities of parenting and sick kids

My children are both young; the youngest is now a little past her second birthday. In the last few years, we have had both infant and children medication in the house, liquid and tablets, and I have been very careful to make sure to double-check myself if I ever have to medicate either child to make sure that I am reading the correct dosing matrix for the correct concentration and for the correct child. More often than not, I have found that children need medication when their parents are tired. As parents know – children frequently get sick in the middle of the night and when children in the house are sick nobody in the household sleeps well. I always try to take this into account to avoid dosing errors. However, this can be confusing particularly when children are little.

When my children were very little, I used to ask the doctor at each appointment what would be the correct Tylenol dose for their current weight. I did not foresee having to use that information, but I wanted to make sure that I knew the correct amount in case I was caught with a sick child in the middle of the night. If it had been a while since my child was weighed, I would sometimes have to call for dosing information. Additionally, I found that it was nearly impossible to dose a child properly using the little cups included with the medication. However, the medicine packaging clearly states that you are only to dose using the enclosed cup. I found that my ability to dose the correct amount of medication was much improved when I used a syringe style dropper.

The FDA steps in – finally!

Well, apparently, I have not been alone in my concerns. The FDA panel that met last week, has made some recommendations that may improve some of these problems in the future and lessen the chances that children will receive too much medication. According to the AP article, the following recommendations have been voted on and will be recommended to the FDA:

Dosing instructions should be added for children younger than 2 years old

Dosing instructions should be provided based on a child’s weight (rather than the focus being on a child’s age)

Limiting cup measurements to milliliters (rather than both teaspoons and milliliters…one of many things that make the current measurement cups confusing)

Mandating a single dosage for children’s solid acetaminophen tablets

Infant Tylenol (and other acetaminophen products) a thing of the past

Relatedly, the article mentioned that the Consumer Healthcare Products Association, which includes the makers of Tylenol and many other acetaminophen producers, agreed to voluntarily stop producing infant drops. This decision means that a day may be coming soon when there would only be one concentration available of children’s acetaminophen.

Some tips and tricks to avoid overdosing your child

If infant acetaminophen is eliminated and children’s acetaminophen is sold with the changed dosing instructions, I think that parents and other caregivers will find it much easier to provide children with the correct amount of medication. However, I would still recommend taking the following steps to protect your children:

Keep all medications, including children’s acetaminophen, in a locked closet or other locked secure location away from children.

Do not forget to re-secure medication, even when children are sick, so that children are not accidentally able to overdose (when using medicine frequently the temptation to leave it accessible should not overcome the safety element of keeping it away from little hands).

Keep a list of the current weight of each child in the house available with the medications so that a caregiver (or tired parent) knows the weight of each child to be able to refer to the dosing chart when needed.

Use a clearly marked cup or syringe that is specifically for medicine to dose your child – do not use a household spoon or other imprecise measuring tool.

If in doubt on dosing, call the pediatrician to be sure – do not guess!

When multiple people will be caring for a sick child (or if you are tired), make sure that you note down the time of each dose of medication to ensure proper timing between doses to avoid accidental overdose.

Read the ingredients on any medication carefully to ensure that you do not give your child multiple medications containing the same ingredient – acetaminophen is sometimes added to other medications in combination drugs.

The best advice

Obviously, since I am not a doctor, you should check with your pediatrician if you have any questions about what the correct method is for providing medication to your child, but these tips will hopefully help eliminate some of the more common medication errors in your home.

Your take?

Do you have other tips to share? What about the recommended changes, do you think that additional changes are needed? Do you use fever-reducing medications in your child if your child is not displaying other symptoms, or do you allow the fever to do its work its way out?

Recently, I have been thinking quite a bit about schools. My son is going to start kindergarten in the fall and my daughter just started preschool last week. While both of my kids are still little, over the years children end up spending many of their waking hours each week at school. The school becomes as much a part of their lives as home for most kids. As parents, we put trust in the school that they will be keeping our children safe and healthy while we are not around to supervise. But do the schools recognize that trust and live up to it?

I was recently made aware of a situation involving a teenager who was having some health concerns. Her parents had first noticed that their daughter seemed to be altering her eating patterns. Since they were not certain if there was a problem forming and what was going on during the school day, they called the school and asked if the school thought that there was any reason to be concerned. This seemed to be a prudent action for any concerned parent. But what, if anything, is the school required to tell the parents? What if the parents had not noticed a problem, but the school knew that something was not right, would they have needed to call it to the parents’ attention?

Legally, it turns out that a school is considered to stand in loco parentis over the children in its care. This fancy legalese just means that the school stands in as substitute parents during the school day. This is true of both public and private schools. The school holds a duty to protect and supervise students in its care. The courts have determined that this includes taking care to protect children from foreseeable harm, the way a reasonable parent would do if they were there.

So what does this all mean? Some of this is pretty straightforward. A school needs to protect your children from harm they could foresee. A school has to take reasonable precautions to protect children from getting hurt on the playground or from cars driving around the campus – to the same extent that a prudent parent would do so. For public policy reasons, schools are often a place where the government often takes an even more active role in monitoring children’s health – for example in doing hearing and vision screenings.

But what about other types of harms? Most parents would want to know if their child was being bullied, was showing signs of developing an eating disorder or was considering hurting him or herself. Does a school have a duty to inform parents anytime there might be a chance of one of these harms?

The law does not seem to be settled in on this point. Generally speaking, the school would need to take reasonable steps to protect a child if the school could foresee that the child was at risk of being harmed by another child in the school. The law is not explicit about whether that includes informing the parents. When the risk is not of another child hurting your child but of your child hurting him or herself, the law is much less clear. In Maryland, it seems possible that a school might have a duty to warn a parent if they believe a child is suicidal. The school counselor may have a duty to warn the parent as part of a duty to take reasonable means to prevent the child’s suicide. However, the law is not explicit about when that duty arises.

What do you think? Does a school have a duty to inform parents if there is a reasonable chance that a child might be a danger to him or herself? What if your child is engaging in behaviors that might cause harm over time? Is this the role of a school?

A few months ago, this blog highlighted the issue of dangerous window treatments. In the original article, I discussed how difficult it was for parents to know whether the window treatments in their home were safe and the relatively small cost it would take for manufacturers to make kids safer. So the unfortunate reality is that despite the ongoing safety concerns and injuries and even deaths due to window blind cords, manufacturers persist in making and selling dangerous blinds and shades that have cords that are accessible to children. This week, the Consumer Product Safety Commission has announced another recall of so-called Roman shades and roll-up blinds. These products have cords that allow a child to become strangled if they get their neck caught between the cord and the fabric or if the child accidentally wraps the cord around their neck. While the recall says that injuries have not yet been reported based on this product, these products are of the same type as many where injuries and deaths have been previously reported. It leaves me to wonder at what point the government or some external force will provide enough pressure on the manufacturers to stop creating and marketing dangerous blinds to the public? As my original post explained the cost savings in manufacturing blinds this way is not extreme, but the costs are huge to families when children are hurt. Furthermore, these products are being sold, at least in this case, at discount stores to families who are likely buying what blinds they can afford without any knowledge of the potential danger.

Photo: www.flickr.com/photos/stvcr/

For several years, there have been periodic news reports about major recalls involving window blinds. Window blind manufacturers have also provided a number of different types of safety elements on their blinds. These have included breakaway plastic pieces on the bottoms of the cords and other sorts of “safer” ways to deal with the cords involved in the use of the blinds. How many of you believed that these recalls and changes meant that new blinds or blinds that had not been subject to any recalls were safe?

As a parent, I thought that I was fairly up-to-date about this issue. I had replaced all of the Roman style blinds in one room in my home with cordless blinds before my daughter was born. I had purchased another type of cordless blind system for the playroom. In the one remaining area with older style blinds, I had carefully checked to make sure that the cords were not tied into a loop and that they were cleated-up high so that no additional cord was accessible at child-height. Then, I basically went on living my life without thinking too much more about it.

Well, a recent New York Times article changed that for me. The article details the injuries and deaths of several children. These children were all severely injured or killed by window blind cords. The disturbing part to me, however, was that many of the parents had taken what I would have considered to be major precautions. They had baby-proofed their homes. They had tied-up the extra cords. Yet still, the boys and girls mentioned were hurt or killed by either the interior cords of the blinds and/or by climbing up and getting tangled in the supposedly secured/safe blind cords.

What a disturbing wake-up call. I certainly walked around my house last night with a different idea of child safety. But, as I mentioned, I know that a cordless type of blind exists. So, why is this not the safety standard?

Now, prodded by a Missouri mother whose daughter was strangled in a window blind, the Consumer Product Safety Commission has asked manufacturers to devise a way to eliminate the risks from window cords or perhaps face mandatory regulations. Critics of the industry complain that manufacturers have dragged their feet on addressing safety hazards for decades, making minor tweaks or putting the onus on parents to shorten cords or buy tie-down devices. Until recently, regulators have done little to crack down, they say.

In response to the commission’s latest push, the industry, working with a task force of regulators and consumer advocates, says it will come up with a fix by the fall.

But the negotiations have gotten off to a rocky start. Like some other regulatory battles that involve consumer safety, this one comes down to a sobering question: how much should manufacturers, and ultimately consumers, be required to pay to prevent the maiming or death of a child?

When I read this, I imagined that it came down to this question because the cost of making all window blinds cordless was prohibitive. The article even states that “… cordless blinds are more difficult to manufacture than corded blinds and can cost considerably more in stores, by some estimates, twice as much.” However, when you examine further, it seems that the cost of cordless blinds might not really be much more and certainly not prohibitively expensive.

The article goes on to say that James G. Onder, a St. Louis lawyer who represents parents whose children have been injured or killed by blinds, “…said manufacturers have repeatedly testified in depositions that the additional cost of making a cordless blind is $1 to $2.” If this is accurate and cordless blinds can be made for $1-2 more per blind, then why are children dying?

The Consumer Product Safety Commission (CPSC) issued a press release in March 2011 that said that:

About half of the deaths of children who strangle in window cords have not been reported, according to an article in this week’s Journal of the American Medical Association and co-authored by a staff member of the U.S. Consumer Product Safety Commission (CPSC).

The study found that 49 percent of the total number of window cord strangulations in the United States were not being reported to the CPSC. The study estimates that total number from 1981 to 1995 was 359. These figures mean that nearly one child is strangling in window cords every two weeks. Almost all of these deaths (93 percent) are children three years old and under.

What does it say if window blind manufacturers are selling cordless blinds for twice as much in stores, when they only cost an additional $1 or $2 additional dollars to make? What does that say about the cost of safety? What message does that send to the parents of the child who dies approximately every 2 weeks from window cord strangulation?

If the window blind manufacturers are not going to make safer blinds of their own, should they be regulated? What about the continued marketing of a product that proclaims to have safety features but is not as safe as it can be for children? Is it worth the risk?

What is a “medical home”? Do you feel like you or your children have a medical home? Is it one that feels comfortable and accessible and all of the things the term “home” implies?

A couple of years ago, I was involved in some policy work surrounding the idea of the medical home and how to better ensure that children in Baltimore City had a medical home. When I first became involved in this project, I thought I understood the concept of a medical home, but I could not really define it. Working with a group of professionals from medical, public health and policy backgrounds, we spent several months furthering our understanding of what is a “medical home” before we could determine how to measure if children had adequate medical homes.

Today, I am not going to delve into that kind of detail about this topic. However, I thought it might be interesting to think about the concept of a medical home and some of the benefits and potential challenges this poses for families. In this post, I’ll provide some definitions of “medical home” and provide some information about how many children are receiving care in a medical home. I’ll address this topic in a future post about alternative health care locations.

I think that the idea of a medical home speaks to an often forgotten concept in providing the best health care with the fewest mistakes – consistency of care from a committed health care provider. The National Center for Medical Home Implementation, which is “a cooperative agreement between the Maternal and Child Health Bureau (MCHB) and the American Academy of Pediatrics (AAP)”, has a website full of information about the medical home. Their definition of medical home is:

A family-centered medical home is not a building, house, hospital, or home healthcare service, but rather an approach to providing comprehensive primary care.

I think that this is a great overview of the concept. The definition continues:

In a family-centered medical home the pediatric care team works in partnership with a child and a child’s family to assure that all of the medical and non-medical needs of the patient are met.

Through this partnership the pediatric care team can help the family/patient access, coordinate, and understand specialty care, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and family.

The American Academy of Pediatrics (AAP) developed the medical home model for delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including those with special health care needs.

I think that we all hope that our health care is provided in a comprehensive way such as is described by this definition. However, too often, we all know that medical care is provided in a more complex web of services in which the patient or patient’s family is left to coordinate care. This reality is even more vivid for those families who are uninsured or under-insured and are not able to receive all of their care from a primary care provider who is able to best coordinate their care.

An article in Bloomberg Business Week reports that a new study found that “Children who have a “medical home” – that is, a pediatrician or nurse they see regularly who offers comprehensive care — are more likely to have their medical and dental needs met…” However, the article goes on to say that children “…who have a chronic condition or special need and require the most care” are the least likely to have a medical home. The article states that only 57% of children in this country “…received care in medical homes in 2007…” The study also found that:

Younger children were more likely to have a medical home than older children.

There were racial and ethnic disparities as well: White children were the most likely to have a medical home, while Hispanic children were the least likely, followed closely by black children.

Mothers without a high school education were significantly less likely to report their children had a medical home, as were the poor, non-English speaking families and the uninsured.

About 61 percent of children whose parents said they were in excellent or very good health had a medical home, compared to 35 percent of kids in fair or poor health.

These children, who are most likely to need a medical home, are the least likely to have one. This is despite research, and common sense, showing that medical homes are able to provide better health care at lower cost. The Bloomberg article says that “[c]hildren without a medical home were three to four times more likely to have an unmet medical or dental need, according to the study, published online March 14 in the journal Pediatrics.” Additionally, “[c]hildren who received care in medical homes were also more likely to have annual preventive medical visits, the study found.”

As I was reading these statistics, I was imagining the children without a medical home as children who often used clinics or emergency rooms for their health care. However, the Bloomberg article says that the study found that

…nearly all children — 93 percent — had a usual source of care, and about the same number had a personal physician or nurse. About 82 percent of parents said they had few problems obtaining referrals, 69 percent said they received help with coordinating care when needed and 67 percent said they received family-centered care.

But only 57 percent of parents reported that the health care their children received met all of those criteria — the definition of a medical home.

It is the comprehensive care provided by all of the elements of the medical home that create the best results in terms of patient care and cost savings. It is this combination that is lacking in many providers of pediatric care.

Do the members of your family receive their care in a medical home? Could you answer yes to all of the questions above defining a medical home? Is this important to you? What would make it easier for you to receive this kind of care for yourself or your child?